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Management of anoperineal lesions in Crohn’s disease: a French National Society of Coloproctology national consensus

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Abstract

The French National Society of Coloproctology established national recommendations for the treatment of anoperineal lesions associated with Crohn’s disease. Treatment strategies for acute abscesses, active fistulas (active denovo and still active under treatment), fistulas in remission, and rectovaginal fistulas are suggested. Recommendations have been graded following the international recommendations, and when absent, professional agreement has been established. For each situation, practical algorithms have been drawn.

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Abbreviations

APL:

Anoperineal lesion

CD:

Crohn’s disease

PA:

Professional agreement

EA:

Expert agreement

MRI:

Nuclear magnetic resonance imaging

IS:

Immunosuppressant

References

  1. Bouchard D, Abramowitz L, Bouguen G, Brochard C, Dabadie A, de Parades V, Eleuet-Kaplan M, Fathallah N, Faucheron J-L, Maggiori L, Panis Y, Pigot F, Roume P, Roumeguere P, Sénéjoux A, Siproudhis L, Staumont G, Suduca J-M, Vinson-Bonnet B, Zeitoun J-D (2017) Anoperineal lesions in Crohn’s disease: French recommendations for clinical practice. Tech Coloproctol 21:683–691. https://doi.org/10.1007/s10151-017-1684-y

    Article  CAS  PubMed  Google Scholar 

  2. Hughes LE (1992) Clinical classification of perianal Crohn’s disease. Dis Colon Rectum 35:928–932

    Article  CAS  Google Scholar 

  3. Parks AG, Gordon PH, Hardcastle JD (1976) A classification of fistula-in-ano. Br J Surg 63:1–12

    Article  CAS  Google Scholar 

  4. Sandborn WJ, Fazio VW, Feagan BG, Hanauer SB (2003) American Gastroenterological Association Clinical Practice Committee. AGA technical review on perianal Crohn’s disease. Gastroenterology 125:1508–1530

    Article  Google Scholar 

  5. Allan A, Linares L, Spooner HA, Alexander-Williams J (1992) Clinical index to quantitate symptoms of perianal Crohn’s disease. Dis Colon Rectum 35:656–661

    Article  CAS  Google Scholar 

  6. Irvine EJ (1995) Usual therapy improves perianal Crohn’s disease as measured by a new disease activity index. McMaster IBD Study Group. J Clin Gastroenterol 20:27–32

    Article  CAS  Google Scholar 

  7. Beets-Tan RG, Beets GL, van der Hoop AG et al (2001) Preoperative MR imaging of anal fistulas: does it really help the surgeon? Radiology 218:75–84

    Article  CAS  Google Scholar 

  8. Buchanan GN, Halligan S, Bartram CI, Williams AB, Tarroni D, Cohen CR (2004) Clinical examination, endosonography, and MR imaging in preoperative assessment of fistula in ano: comparison with outcome-based reference standard. Radiology 233:674–681

    Article  Google Scholar 

  9. Orsoni P, Barthet M, Portier F, Panuel M, Desjeux A, Grimaud JC (1999) Prospective comparison of endosonography, magnetic resonance imaging and surgical findings in anorectal fistula and abscess complicating Crohn’s disease. Br J Surg 86:360–364

    Article  CAS  Google Scholar 

  10. Schwartz DA, Wiersema MJ, Dudiak KM et al (2001) A comparison of endoscopic ultrasound, magnetic resonance imaging, and exam under anesthesia for evaluation of Crohn’s perianal fistulas. Gastroenterology 121:1064–1072

    Article  CAS  Google Scholar 

  11. Sordo-Mejia R, Gaertner WB (2014) Multidisciplinary and evidence-based management of fistulizing perianal Crohn’s disease. World J Gastrointest Pathophysiol 5:239–251

    Article  Google Scholar 

  12. Thia KT, Mahadevan U, Feagan BG et al (2009) Ciprofloxacin or metronidazole for the treatment of perianal fistulas in patients with Crohn’s disease: a randomized, double-blind, placebo-controlled pilot study. Inflamm Bowel Dis 15:17–24

    Article  Google Scholar 

  13. Maeda Y, Ng SC, Durdey P et al (2010) Topical metronidazole in perianal Crohn’s Study Group. Randomized clinical trial of metronidazole ointment versus placebo in perianal Crohn’s disease. Br J Surg 97:1340–1347

    Article  CAS  Google Scholar 

  14. Dewint P, Hansen BE, Verhey E et al (2014) Adalimumab combined with ciprofloxacin is superior to adalimumab monotherapy in perianal fistula closure in Crohn’s disease: a randomised, double-blind, placebo controlled trial (ADAFI). Gut 63:292–299

    Article  CAS  Google Scholar 

  15. West RL, van der Woude CJ, Hansen BE et al (2004) Clinical and endosonographic effect of ciprofloxacin on the treatment of perianal fistulas in Crohn’s disease with infliximab: a double-blind placebo-controlled study. Aliment Pharmacol Ther 20:1329–1336

    Article  CAS  Google Scholar 

  16. Ruemmele FM, Veres G, Kolho KL et al (2014) European Crohn’s and Colitis Organisation; European Society of Pediatric Gastroenterology, Hepatology and Nutrition. Consensus guidelines of ECCO/ESPGHAN on the medical management of pediatric Crohn’s disease. J Crohns Colitis 8:1179–1207

    Article  CAS  Google Scholar 

  17. Malik AI, Nelson RL, Tou S (2010) Incision and drainage of perianal abscess with or without treatment of anal fistula. Cochrane Database Syst Rev 7:CD006827

    Google Scholar 

  18. El-Gazzaz G, Hull T, Church JM (2012) Biological immunomodulators improve the healing rate in surgically treated perianal Crohn’s fistulas. Colorectal Dis 14:1217–1223

    Article  CAS  Google Scholar 

  19. Hyder SA, Travis SP, Jewell DP, Mortensen NJM, George BD (2006) Fistulating anal Crohn’s disease: results of combined surgical and infliximab treatment. Dis Colon Rectum 49:1837–1841

    Article  Google Scholar 

  20. Yassin NA, Askari A, Warusavitarne J et al (2014) Systematic review: the combined surgical and medical treatment of fistulising perianal Crohn’s disease. Aliment Pharmacol Ther 40:741–749

    Article  CAS  Google Scholar 

  21. Regueiro M, Mardini H (2003) Treatment of perianal fistulizing Crohn’s disease with infliximab alone or as an adjunct to exam under anesthesia with seton placement. Inflamm Bowel Dis 9:98–103

    Article  Google Scholar 

  22. Crandall W, Hyams J, Kugathasan S et al (2009) Infliximab therapy in children with concurrent perianal Crohn disease: observations from REACH. J Pediatr Gastroenterol Nutr 49:183–190

    Article  CAS  Google Scholar 

  23. Dupont-Lucas C, Dabadie A, Alberti C, Ruemmele FM (2014) GETAID (Group d’Etude Thérapeutique des Affections Inflammatoires du Tube Digestif) Pédiatrique. Predictors of response to infliximab in paediatric perianal Crohn’s disease. Aliment Pharmacol Ther 40:917–929

    Article  CAS  Google Scholar 

  24. Lee MJ, Heywood N, Sagar PM, Brown SR, Fearnhead NS, ACPGBI Perianal Crohn’s Disease Group (2017) Association of Coloproctology of Great Britain and Ireland consensus exercise on surgical management of fistulating perianal Crohn’s disease. Colorectal Dis 19:418–429

    Article  CAS  Google Scholar 

  25. Vial M, Parés D, Pera M, Grande L (2010) Faecal incontinence after seton treatment for anal fistulae with and without surgical division of internal anal sphincter: a systematic review. Colorectal Dis 12:172–178

    Article  CAS  Google Scholar 

  26. Zhang H, Zhou ZY, Hu B et al (2016) Clinical significance of 2 deep posterior perianal spaces to complex cryptoglandular fistulas. Dis Colon Rectum 59:766–774

    Article  Google Scholar 

  27. Sheedy SP, Bruining DH, Dozois EJ, Faubion WA, Fletcher JG (2017) MR imaging of perianal crohn disease. Radiology 282:628–645

    Article  Google Scholar 

  28. Tanaka S, Matsuo K, Sasaki T et al (2010) Clinical advantages of combined seton placement and infliximab maintenance therapy for perianal fistulizing Crohn’s disease: when and how were the seton drains removed? Hepatogastroenterology 57:3–7

    CAS  PubMed  Google Scholar 

  29. Present DH, Rutgeerts P, Targan S et al (1999) Infliximab for the treatment of fistulas in patients with Crohn’s disease. N Engl J Med 340:1398–1405

    Article  CAS  Google Scholar 

  30. Sands BE, Anderson FH, Bernstein CN et al (2000) Infliximab maintenance therapy for fistulizing Crohn’s disease. N Engl J Med 350:876–885

    Article  Google Scholar 

  31. Colombel JF, Sandborn WJ, Rutgeerts P et al (2007) Adalimumab for maintenance of clinical response and remission in patients with Crohn’s disease: the CHARM trial. Gastroenterology 132:52–65

    Article  CAS  Google Scholar 

  32. Echarri A, Castro J, Barreiro M, Carpio D, Pereira S, Lorenzo A (2010) Evaluation of adalimumab therapy in multidisciplinary strategy for perianal Crohn’s disease patients with infliximab failure. J Crohns Colitis 4:654–660

    Article  Google Scholar 

  33. Ford AC, Sandborn WJ, Khan KJ et al (2011) Efficacy of biological therapies in inflammatory bowel disease: systematic review and meta-analysis. Am J Gastroenterol 106:644–659

    Article  CAS  Google Scholar 

  34. Moon W, Pestana L, Becker B, Loftus EV Jr, Hanson KA, Bruining DH, Tremaine WJ, Kane SV (2015) Efficacy and safety of certolizumab pegol for Crohn’s disease in clinical practice. Aliment Pharmacol Ther 42:428–440

    Article  CAS  Google Scholar 

  35. Sandborn WJ, Feagan BG, Rutgeerts P et al (2013) GEMINI 2 Study Group. Vedolizumab as induction and maintenance therapy for Crohn’s disease. N Engl J Med 369:711–721

    Article  CAS  Google Scholar 

  36. Pearson DC, May GR, Fick GH, Sutherland LR (1995) Azathioprine and 6-mercaptopurine in Crohn disease. A meta-analysis. Ann Intern Med 123:132–142

    Article  CAS  Google Scholar 

  37. Prefontaine E, Macdonald JK, Sutherland LR (2010) Azathioprine or 6-mercaptopurine for induction of remission in Crohn’s disease. Cochrane Database Syst Rev 6:CD000545

    Google Scholar 

  38. Cosnes J, Bourrier A, Laharie D et al (2013) Groupe d’Etude Thérapeutique des Affections Inflammatoires du Tube Digestif (GETAID). Early administration of azathioprine vs conventional management of Crohn’s disease: a randomized controlled trial. Gastroenterology 145:758–765

    Article  CAS  Google Scholar 

  39. Panés J, López-Sanromán A, Bermejo F et al, AZTEC Study Group (2013) Early azathioprine therapy is no more effective than placebo for newly diagnosed Crohn’s disease. Gastroenterology 145:766–774

    Article  Google Scholar 

  40. Chande N, Patton PH, Tsoulis DJ, Thomas BS, MacDonald JK (2015) Azathioprine or 6-mercaptopurine for maintenance of remission in Crohn’s disease. Cochrane Database Syst Rev 10:CD000067

    Google Scholar 

  41. Gonsalves S, Sagar P, Lengyel J, Morrison C, Dunham R (2009) Assessment of the efficacy of the rectovaginal button fistula plug for the treatment of ileal pouch-vaginal and rectovaginal fistulas. Dis Colon Rectum 52:1877–1881

    Article  Google Scholar 

  42. Hart AL, Plamondon S, Kamm MA (2007) Topical tacrolimus in the treatment of perianal Crohn’s disease: exploratory randomized controlled trial. Inflamm Bowel Dis 13:245–253

    Article  Google Scholar 

  43. Colombel JF, Sandborn WJ, Reinisch W et al (2010) SONIC Study Group. Infliximab, azathioprine, or combination therapy for Crohn’s disease. N Engl J Med 362:1383–1395

    Article  CAS  Google Scholar 

  44. Bouguen G, Siproudhis L, Gizard E et al (2013) Long-term outcome of perianal fistulizing Crohn’s disease treated with infliximab. Clin Gastroenterol Hepatol 11:975–981.e1–4

    Article  CAS  Google Scholar 

  45. Molendijk I, Bonsing BA, Roelofs H et al (2015) Allogeneic bone marrow-derived mesenchymal stromal cells promote healing of refractory perianal fistulas in patients with Crohn’s disease. Gastroenterology 149:918–927.e6

    Article  Google Scholar 

  46. Panés J, García-Olmo D, Van Assche G et al, ADMIRE CD Study Group Collaborators (2016) Expanded allogeneic adipose-derived mesenchymal stem cells (Cx601) for complex perianal fistulas in Crohn’s disease: a phase 3 randomised, double-blind controlled trial. Lancet 388:1281–1290

    Article  Google Scholar 

  47. Van Assche G, Vanbeckevoort D, Bielen D et al (2003) Magnetic resonance imaging of the effects of infliximab on perianal fistulizing Crohn’s disease. Am J Gastroenterol 98:332–339

    Article  Google Scholar 

  48. Tougeron D, Savoye G, Savoye-Collet C, Koning E, Michot F, Lerebours E (2009) Predicting factors of fistula healing and clinical remission after infliximab-based combined therapy for perianal fistulizing Crohn’s disease. Dig Dis Sci 54:1746–1752

    Article  CAS  Google Scholar 

  49. Braithwaite GC, Lee MJ, Hind D, Brown SR (2017) Prognostic factors affecting outcomes in fistulating perianal Crohn’s disease: a systematic review. Tech Coloproctol 21:501–519. https://doi.org/10.1007/s10151-017-1647-3

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  50. Karmiris K, Bielen D, Vanbeckevoort D et al (2011) Long-term monitoring of infliximab therapy for perianal fistulizing Crohn’s disease by using magnetic resonance imaging. Clin Gastroenterol Hepatol 9:130–136

    Article  CAS  Google Scholar 

  51. Savoye-Collet C, Savoye G, Koning E, Dacher JN, Lerebours E (2011) Fistulizing perianal Crohn’s disease: contrast-enhanced magnetic resonance imaging assessment at 1 year on maintenance anti-TNF-alpha therapy. Inflamm Bowel Dis 17:1751–1758

    Article  CAS  Google Scholar 

  52. Colombel JF, Schwartz DA, Sandborn WJ et al (2009) Adalimumab for the treatment of fistulas in patients with Crohn’s disease. Gut 58:9 40–48

    Article  CAS  Google Scholar 

  53. Gaertner WB, Decanini A, Mellgren A et al (2007) Does infliximab infusion impact results of operative treatment for Crohn’s perianal fistulas? Dis Colon Rectum 50:1754–1760

    Article  Google Scholar 

  54. Haenning A, Staumont G, Lepage B et al (2015) The results of seton drainage combined with anti-TNF therapy for anal fistula in Crohn’s disease. Colorectal Dis 17:311–319

    Article  Google Scholar 

  55. Lichtenstein GR, Yan S, Bala M, Blank M, Sands BE (2005) Infliximab maintenance treatment reduces hospitalizations, surgeries, and procedures in fistulising Crohn’s disease. Gastroenterology 128:862–869

    Article  CAS  Google Scholar 

  56. Feagan BG, Panaccione R, Sandborn WJ et al (2008) Effects of adalimumab therapy on incidence of hospitalization and surgery in Crohn’s disease: results from the CHARM study. Gastroenterology 135:1493–1499

    Article  CAS  Google Scholar 

  57. Sands BE, Blank MA, Diamond RH, Barrett JP, Van Deventer SJ (2006) Maintenance infliximab does not result in increased abscess development in fistulising Crohn’s disease: results from the ACCENT II study. Aliment Pharmacol Ther 23:1127–1136

    Article  CAS  Google Scholar 

  58. Roumeguère P, Bouchard D, Pigot F et al (2011) Combined approach with infliximab, surgery, and methotrexate in severe fistulizing anoperineal Crohn’s disease: results from a prospective study. Inflamm Bowel Dis 17:69–76

    Article  Google Scholar 

  59. Grimaud JC, Munoz-Bongrand N, Siproudhis L et al (2010) Groupe d’Etude Thérapeutique des Affections Inflammatoires du Tube Digestif. Fibrin glue is effective healing perianal fistulas in patients with Crohn’s disease. Gastroenterology 138:2275–2281, 2281.e1

    Article  CAS  Google Scholar 

  60. Senéjoux A, Siproudhis L, Abramowitz L et al (2016) Groupe d’Etude Thérapeutique des Affections Inflammatoires du tube Digestif [GETAID]. Fistula plug in fistulising ano-perineal Crohn’s disease: a randomised controlled trial. J Crohns Colitis 10:141–148

    Article  Google Scholar 

  61. Gingold DS, Murrell ZA, Fleshner PR (2014) A prospective evaluation of the ligation of the intersphincteric tract procedure for complex anal fistula in patients with Crohn’s disease. Ann Surg 260:1057–1061

    Article  Google Scholar 

  62. Joo JS, Weiss EG, Nogueras JJ, Wexner SD (1998) Endorectal advancement flap in perianal Crohn’s disease. Am Surg 64:147–150

    CAS  PubMed  Google Scholar 

  63. Makowiec F, Jehle EC, Becker HD, Starlinger M (1995) Clinical course after transanal advancement flap repair of perianal fistula in patients with Crohn’s disease. Br J Surg 82:603–606

    Article  CAS  Google Scholar 

  64. Jones IT, Fazio VW, Jagelman DG (1987) The use of transanal rectal advancement flaps in the management of fistulas involving the anorectum. Dis Colon Rectum 30:919–923

    Article  CAS  Google Scholar 

  65. van Onkelen RS, Gosselink MP, Schouten WR (2012) Is it possible to improve the outcome of transanal advancement flap repair for high transsphincteric fistulas by additional ligation of the intersphincteric fistula tract? Dis Colon Rectum 55:163–166

    Article  Google Scholar 

  66. Corte H, Maggiori L, Treton X, Lefevre JH, Ferron M, Panis Y (2015) Rectovaginal fistula. Ann Surg 262:855–861

    Article  Google Scholar 

  67. Gajsek U, CDArthur DR, Sagar PM (2011) Long-term efficacy of the button fistula plug in the treatment of Ileal pouch-vaginal and Crohn’s-related rectovaginal fistulas. Dis Colon Rectum 54:999–1002

    Article  CAS  Google Scholar 

  68. Ruffolo C, Scarpa M, Bassi N, Angriman I (2010) A systematic review on advancement flaps for rectovaginal fistula in Crohn’s disease: transrectal vs transvaginal approach. Colorectal Dis 12:1183–1191

    Article  CAS  Google Scholar 

  69. Pinto RA, Peterson TV, Shawki S, Davila GW, Wexner SD (2010) Are there predictors of outcome following rectovaginal fistula repair? Dis Colon Rectum 53:1240–1247

    Article  Google Scholar 

  70. Mege D, Frasson M, Maggiori L, Panis Y (2016) Is biological mesh interposition a valid option for complex or recurrent rectovaginal fistula? Colorectal Dis 18:O61–O65

    Article  CAS  Google Scholar 

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Funding

This work was supported by the French National Society of Coloproctology (SNFCP) and the Groupe d’Etudes Thérapeutique des Affections Inflammatoires du Tube digestif (GETAID).

Author information

Authors and Affiliations

  1. Hôpital Bagatelle, 203 Route de Toulouse, 33401, Talence Cedex, France

    D. Bouchard & F. Pigot

  2. Clinique Saint Jean du Languedoc, 20 Route de Revel, 31400, Toulouse, France

    G. Staumont

  3. Centre Hospitalier Universitaire, 35033, Rennes Cedex 9, France

    L. Siproudhis & C. Brochard

  4. Centre Hospitalier Universitaire Bichat, 75877, Paris, France

    L. Abramowitz

  5. Hôpital Saint Joseph, 185 Rue Raymond Losserand, 75014, Paris, France

    P. Benfredj, N. Fathallah & V. de Parades

  6. Centre Hospitalier Universitaire Grenoble-Alpes, Avenue Maquis du Grésivaudan, 38700, La Tronche, France

    J.-L. Faucheron

  7. 11 Boulevard du Général Leclerc, 06240, Beausoleil, France

    T. Higuero

  8. Hôpital Beaujon, 100 Boulevard du Général Leclerc, 92110, Clichy, France

    Y. Panis

  9. Hôpital de Poissy-Saint Germain en Laye, 10 Rue Champ Gaillard, 78300, Poissy, France

    B. Vinson-Bonnet

  10. Centre Hospitalier Universitaire Haut Lévêque, Avenue Magellan, 33604, Pessac Cedex, France

    D. Laharie

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  1. D. Bouchard
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  2. F. Pigot
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Correspondence to D. Bouchard.

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Conflict of interest

Dominique Bouchard is the recipient of fees for education and consulting from Abbvie, François Pigot is the recipient of fees for lectures from Abbvie, Laurent Siproudhis is the recipient of fees for consulting, teaching and research from Abbvie, Ferring, MSD and Takeda, Laurent Abramowitz is the recipient of fees for research from Abbvie and Takeda, Jean-Luc Faucheron is the recipient of fees for consulting and research from AMI and Medtronic, David Laharie is the recipient of fees for consulting and research from Abbvie, Janssen, MSD and Takeda, Ghislain Staumont, Paul Benfredj, Charlène Brochard, Nadia Fathallah, Thierry Higuero, Yves Panis, Vincent de Parades, and Béatrice Vinson-Bonnet have no conflict of interest or financial ties to disclose.

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Bouchard, D., Pigot, F., Staumont, G. et al. Management of anoperineal lesions in Crohn’s disease: a French National Society of Coloproctology national consensus. Tech Coloproctol 22, 905–917 (2018). https://doi.org/10.1007/s10151-018-1906-y

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